Qualifying for Medicare Due to Disability – Special Circumstances, Special Considerations

Posted by Medicare Made Clear

Not everyone has to wait until they turn 65 to become eligible for Medicare coverage. Many people with disabilities and other special circumstances become eligible for Medicare well before their 65th birthdays. If you or a loved one have recently become disabled, now may be the time to start learning about Medicare plan choices.

First Things First

If you think you might qualify for Medicare due to a disability, you should first file for disability benefits through Social Security. Approval of your request is an important first step to take before you will be considered eligible for Medicare. For more information, contact Social Security at 1-800-772-1213; TTY 1-800-325-0778 (7 a.m. – 7 p.m., local time, Monday – Friday).

When Am I Eligible?

Automatic Enrollment in Original Medicare: After you’ve been receiving disability benefits from Social Security (SSA) or the Railroad Retirement Board (RRB) for 24 months, you’ll automatically be enrolled in Original Medicare. Coverage will start the first day of month 25.

If you have Amyotrophic Lateral Sclerosis (ALS; also called Lou Gehrig’s disease), there is no waiting period. You are automatically enrolled in Original Medicare (Parts A and B) as soon as your disability benefits begin.

If you have End-Stage Renal Disease (ESRD), you will not be automatically enrolled in Original Medicare. You need to contact your local Social Security office to enroll (1-800-772-1213; TTY 1-800-325-0778; 7 a.m. – 7 p.m., local time, Monday – Friday).

If you don’t qualify for Medicare due to disability, but have a chronic condition such as diabetes or Congestive Heart Failure (CHF), you might qualify for a Medicare Advantage Special Needs Plan (SNP). Contact specific plan providers for more details and eligibility information.

Initial Enrollment Period: If you qualify for Medicare due to a disability and are under 65, your Medicare Initial Enrollment Period (IEP) will mainly come into play if you want to enroll in a Medicare Advantage plan or Medicare Part D prescription coverage. If you choose to enroll in either type of plan, “25” is the magic number. First, figure out when the 25th month of your disability will be. Your Initial Enrollment Period will be a 7-month period surrounding that date: the 3 months before your 25th month of disability, the 25th month of your disability and the 3 months after your 25th month of disability. Even if you sign up at the early end of that period, coverage will begin after you have been eligible for disability benefits for 24 full months. Then, when you are about to turn 65, the normal Medicare Initial Enrollment Period dates will apply.

Other Enrollment Periods: Once you have Medicare coverage, you can add, switch or drop any coverage during the Annual Enrollment Period (October 15 – December 7) each year. If you need to make changes during other times of the year, you will need to see if you or your loved one qualify for a Special Enrollment Period (SEP).

Medicare Supplement Insurance Open Enrollment Period: In some states, Medicare Supplement Insurance plans are available to people eligible for Medicare due to disability, even if they’re under 65. This isn’t true in all states, so be sure to look for plans that are available in your area.

Once you’ve heard from Social Security that you’re eligible for Medicare due to disability, you might be wondering what your next steps might be. We can help. The Medicare Made Clear Disability Enrollment Roadmap was designed to walk you through the steps you need to take to get Medicare coverage if you qualify due to a disability. The “Preparation” section acts as a checklist of things to do before you enroll in Medicare. Do you understand the parts of Medicare and what is available in your area or state? Do you have a checklist of Medicare coverage needs? Once you’ve laid the foundation, the rest of the roadmap helps you learn about important enrollment guidelines and deadlines.

For more information, contact the Medicare helpline 24 hours a day, 7 days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies. For Medicare Advantage and Prescription Drug Plans: A Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare.